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Oregon Emergency Communications
FOR REVENUE USE ONLY
Date received
Tax Registration for
Oregon Business Identification Number (BIN)
Business identification number (BIN)
Business name
Federal employer identification number (FEIN)
Physical address of business
City
State
ZIP code
County
Mailing address
City
State
ZIP code
Business telephone number
(if different from above)
Where are business records stored?
City
State
ZIP code
Fax number
Type of organization
Sole proprietor
Partnership
Corporation
LLC —
Organized as a sole proprietor
Organized as partnership
Other ___________________________
Organized as a corporation
Names of owner, partner, or corporation officers. Please print clearly (use additional sheets if necessary):
Name
Street address
City, state, ZIP code
Social Security number
Contact person
Telephone number
Date business began offering service in Oregon?
Nature of business
Telecommunications utility
Cellular telephone company
Pre-paid wireless
VOIP
Other __________________________________________________
(Describe)
At registration, I elect to pay the tax based on the following method. You cannot change this method unless you first
obtain permission from the Oregon Department of Revenue (ORS 403.215):
Method 1—Amount of tax collected during the quarter.
Method 2—Net amount of tax billed during the quarter (gross amount billed less adjustments for uncollectible
accounts, refunds, incorrect billings, and other appropriate adjustments).
This information will be used primarily by the Oregon Department of Revenue for identification and compliance purposes
in the administration of the Emergency Communications Tax Program.
Under penalty of false swearing, I declare the information in this document and any attachments is true, correct, and
complete.
Signature
Title
Date
X
150-603-002 (Rev. 02-14)
Mail to: Emergency Communications Tax
Oregon Department of Revenue
PO Box 14110
Salem OR 97309-0910
Or fax to: 503-947-2255
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